A nurse is assisting with the care of a client 2 hr postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

Check the client's distal pulses in both legs.

Keep the client overnight.

Keep the client on bed rest for 12 hr.

Restrict the client's oral fluids.

Answer and Explanation

The Correct Answer is A

A. Check the client's distal pulses in both legs:

Checking the client's distal pulses in both legs is crucial to ensure that there is adequate blood flow and no signs of arterial occlusion or complications from the catheterization. This is an important assessment to detect potential vascular complications, such as a hematoma or an arterial blockage.

B. Keep the client overnight:

Keeping the client overnight is not typically required for all cardiac catheterization procedures. The need for an overnight stay depends on the individual case and any complications or comorbidities. Routine catheterizations often allow for discharge on the same day with appropriate monitoring.

C. Keep the client on bed rest for 12 hr:

Keeping the client on bed rest for 12 hours is excessive. Typically, bed rest is required for 2 to 6 hours following the procedure to allow the puncture site to stabilize and reduce the risk of bleeding. The exact duration of bed rest depends on the approach used and the patient's condition.

D. Restrict the client's oral fluids:

Restricting the client's oral fluids is generally not appropriate. In fact, increasing fluid intake is often encouraged to help flush out the contrast dye used during the procedure and to prevent renal complications. Monitoring for fluid balance is important, but outright restriction is not typically indicated unless there is a specific medical reason.

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Free Nursing Study Resources

Correct Answer is D

Explanation

(A) Determine the client’s blood pressure 1 min after each position change: While it’s important to check the client’s blood pressure after each position change when assessing for orthostatic hypotension, this is not the first step. The nurse should first establish a baseline blood pressure reading with the client in a supine position.

(B) Place the client in a sitting position: Although the nurse will eventually need to check the client’s blood pressure in a sitting position, the first step is to get a baseline reading with the client in a supine position.

(C) Assist the client into a standing position: The nurse will eventually assist the client into a standing position to check for changes in blood pressure, but this is not the first step. The initial step is to get a baseline reading with the client in a supine position.

(D) Check the blood pressure with the client in a supine position: This is the most appropriate first step. When checking for orthostatic hypotension, the nurse should first check the client’s blood pressure while they are lying flat (supine). This provides a baseline reading against which subsequent readings (taken when the client is sitting and standing) can be compared. If there’s a significant drop in blood pressure upon standing, this could indicate orthostatic hypotension.

A. Increase the heat in the client's room. B. Perform nasotracheal suctioning for the client. C. Place the head of the client's bed flat. D. Administer an opioid narcotic to the client.

Correct Answer is D

Explanation

(A) Increase the heat in the client’s room: Increasing the heat in the client’s room is not typically recommended for a client experiencing dyspnea. Heat can sometimes make breathing more difficult, and it does not address the underlying cause of the dyspnea.

(B) Perform nasotracheal suctioning for the client: Nasotracheal suctioning can be used to clear the airway in certain situations, but it is not typically the first-line treatment for dyspnea in a client at the end of life. It can be uncomfortable and distressing for the client.

(C) Place the head of the client’s bed flat: Placing the head of the bed flat can actually make breathing more difficult for a client experiencing dyspnea. It is generally more helpful to elevate the head of the bed to facilitate easier breathing.

(D) Administer an opioid narcotic to the client: This is the most appropriate answer. Opioid narcotics can help to relieve dyspnea in clients at the end of life by reducing anxiety, decreasing the sensation of breathlessness, and improving the client’s overall comfort level. The use of opioids in this context should be carefully monitored to manage potential side effects.

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A nurse is assisting with the care of a client 2 hr postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

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Correct Answer is D

Explanation

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Correct Answer is D

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